MadisonCounty FinanceOffice P.O.Box547
PLEASEMAKECHECKS Payableandmailto: Phone:(859)6244742 Fax:(859)6244027
Richmond,KY404760547
$$ Date___/_____/_______
FormMC100Rev.05/15/2007

Year Year
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6
FORPERIODENDING
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88.BALANCEDUE(totalline5+6+7) Iherebycertifythattheinformation,schedules,statements,andexhibitsfieldherewitharetrueandcorrect. Signed OfficialTitle________________________________________________

AccountNumber PhoneNumber

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EMPLOYER'SRETURNOFLICENSEFEEWITHHELD
MadisonCountyFinanceOffice
Ifnowageswerepaidthisperiod,mark"NONE"andreturnthisform *PLEASEMAKEACOPYOFTHISFORMFORYOURRECORDS.

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llingPenalty5%permonth,maxof25%,Min.$25.00
bberofEmployees

1.Num 2.Salaries,wagesandcommissionspaidtoemployeesperformingservices. 3.Adjustmentofexemptwages(outsideMadisonCo.) 4.TaxableearningsMadisonCo. 5.TOTALLICENSEFEEDUE(LINE4X.01) 6.LateFi 7.InterestPenalty12%perannumorportionofyear.